Soft-tissue images. Proximal jejunal gastrointestinal stromal tumour.

a 3-month history of progresssive abdominal pain, occasional nausea and vomiting. On physical examination, a large abdominal mass was palpated. Computed tomography showed a large mass, measuring 13 × 18 cm, with a fluid-filled centre and irregular walls (Fig. 1). The upper aspect of the mass was indistinguishable from the inferior body of the pancreas and displaced the stomach ventrally (Fig. 2, arrow). Five days later, on repeat computed tomography and biopsy, air was noted within the lumen of the mass (Fig. 3). The patient was immediately transferred to a tertiary care hospital, where he experienced a syncopal episode followed by significant melena. He became hemodynamically unstable. His hemoglobin level dropped from 139 g/L to 91 g/L. At operation, a centrally located large vascular tumour was found, which appeared to arise from the pancreas. When the distal pancreas and spleen were mobilized and resected with the tumour, it was apparent that the mass arose from the jejunum, 10 cm proximal to the ligament of Treitz. Dissection of the mass revealed a cavity filled with several litres of clotted blood and air. A hole was found between the jejunum and the tumour. In retrospect, computed tomography showed that the mass was related to the jejunum (Fig. 2, arrowhead). On pathological examination the operative specimen was found to be a malignant gastrointestinal stromal tumour arising from the proximal jejunum. The patient made a smooth recovery. Gastrointestinal stromal tumours can grow to a large size, resulting in abdominal pain, as in this patient. About 20% of these tumours arise from the small intestine. Upper gastrointestinal bleeding is not uncommon, but perforation and bleeding between the tumour and the bowel has not been reported. These tumours have recently been shown to be commonly associated with a mutation of the KIT gene that may respond to the tyrosine kinase inhibitor ST1571.